CARE HOMES FOR OLDER PEOPLE
Knowle Hill Streetfields Halfway Sheffield South Yorkshire S20 4TB Lead Inspector
Shirley Samuels Unannounced Inspection 2nd February 2006 10:25 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information
Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Knowle Hill DS0000002978.V280444.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Knowle Hill DS0000002978.V280444.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION
Name of service Knowle Hill Address Streetfields Halfway Sheffield South Yorkshire S20 4TB 0114 248 3594 0114 248 0018 diane.harrison@sheffcare.co.uk Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Sheffcare Limited Susan Skinner Care Home 40 Category(ies) of Old age, not falling within any other category registration, with number (40) of places Knowle Hill DS0000002978.V280444.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 12th October 2005 Brief Description of the Service: Knowle Hill is a purpose built home for older people. It is in a residential area of Sheffield with good access to public services, such as bus routes, shops and public houses. Accommodation is provided over three floors, accessed by a lift. All of the bedrooms are single. Each floor is provided with a communal lounge and dining room. Sufficient bathing facilities are provided. The gardens are landscaped and a small car park is available. Knowle Hill DS0000002978.V280444.R01.S.doc Version 5.1 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This was an unannounced inspection carried out over four hours from 10:252:20. Ten service users, six staff, one professional visitor and the manager of the home were spoken to. A selection of records was checked and an inspection of the building was made. What the service does well: What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Knowle Hill DS0000002978.V280444.R01.S.doc Version 5.1 Page 6 DETAILS OF INSPECTOR FINDINGS CONTENTS
Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Knowle Hill DS0000002978.V280444.R01.S.doc Version 5.1 Page 7 Choice of Home
The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2 and 3. Each service user had a contact and terms and conditions. There was an example of a service user being admitted to the home without the home first obtaining a copy of the full needs assessment EVIDENCE: Three service user files were checked, they all contained a copy of the contact and details of the terms and conditions of their stay. This ensured that service users and their NOK knew what to expect. For one of the three service users, the home had not received a copy of the full needs assessment. This resulted in staff not having the information required by the regulations and a lack of written information on which to base a plan of care. Knowle Hill DS0000002978.V280444.R01.S.doc Version 5.1 Page 8 Health and Personal Care
The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 9 and 11. Service users where appropriate are able to administer their own medication. There are policies and procedures in place regarding medication. These however did not prevent medication administration records being inaccurate. Two of the three care plans examined did not contain information on dying and death. EVIDENCE: Gaps were found in a number of medication administration recordings. There was one example of instructions about self-medicating not being clear on the records. The manager submitted to the CSCI an action plan for monitoring the medication procedures, which included temporarily reducing the number of staff administering medication. Implementing extra monitoring. Providing extra training and supervision where needed with a phased, planned reintroduction for other staff members. Two care plans did not contained information on the residents’ wishes regarding funeral arrangements, to ensure these would be carried out.
Knowle Hill DS0000002978.V280444.R01.S.doc Version 5.1 Page 9 Daily Life and Social Activities
The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards not assessed on this occasion. EVIDENCE: Knowle Hill DS0000002978.V280444.R01.S.doc Version 5.1 Page 10 Complaints and Protection
The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards not checked on this occasion EVIDENCE: Knowle Hill DS0000002978.V280444.R01.S.doc Version 5.1 Page 11 Environment
The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,24 and 26. The home was clean and free from odours. Parts of the environments decoration was aged and worn. Residents’ bedrooms were, in the main, well decorated. EVIDENCE: The home is generally maintained to an acceptable standard, some parts of the environment had aged decoration and required refurbishment. The ground floor corridor area and some bedrooms had damaged decoration. The manager said there was a plan in place for redecoration and plans for the replacement of all the windows and resurfacing of the grounds. Service users said communal areas are comfortable. All of the bedrooms were clean and contained residents personal possessions. Service users said they were happy with their rooms and that staff respected their privacy. Liquid soap is provided in all the toilets. Blue aprons for staff to wear when entering the kitchen are available. This ensured the control of infection.
Knowle Hill DS0000002978.V280444.R01.S.doc Version 5.1 Page 12 Staffing
The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 29. Service users are protected and supported by the homes recruitment policies and practises. EVIDENCE: The information regarding staff, required by the regulations are kept electronically, these were examined and fully met the standards. This promoted the protection and support of service users. Knowle Hill DS0000002978.V280444.R01.S.doc Version 5.1 Page 13 Management and Administration
The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 35 and 38. Service users financial interests are safeguarded by the homes policies and procedures. Some updates on food hygiene and moving and handling training are required for staff. Fire systems are checked and serviced. Not all staff had undertaken fire training at the required frequency. EVIDENCE: The records showed that several staff were out of date with aspects of training, such as moving and handling and food hygiene. Some staff had not received fire instruction at the required frequency. The manager agreed to ensure that all staff receive moving and handling and fire training by 12/2/06. Knowle Hill DS0000002978.V280444.R01.S.doc Version 5.1 Page 14 The manager submitted details of the action taken dated 8/2/ 06 which showed that apart from two members of staff for which dates were booked all other staff had now received fire instruction and taken part in a fire drill. Knowle Hill DS0000002978.V280444.R01.S.doc Version 5.1 Page 15 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from:
4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable
CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 x 3 2 x x x HEALTH AND PERSONAL CARE Standard No Score 7 x 8 x 9 3 10 x 11 2 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 x 14 x 15 x COMPLAINTS AND PROTECTION Standard No Score 16 x 17 x 18 x 3 x x x x 3 x 3 STAFFING Standard No Score 27 x 28 x 29 3 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score x x x x x x x 2 Knowle Hill DS0000002978.V280444.R01.S.doc Version 5.1 Page 16 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP3 Regulation 14 Requirement Service users must not move into the home without the home first obtaining a copy of the full needs assessment. Medication administration records must be fully completed. Records must be signed to indicate whether the resident has received their medication. (Previous timescale of 23/11/05 and 31/12/05 not met) Residents’ wishes regarding funeral arrangements must be recorded. Where this information is refused, this must also be recorded. (Previous timescale of 31/12/05 not met) All staff must receive fire instruction twice yearly. Those staff that have not received instruction must do so during their next shift on duty. Records of this training must be forwarded to the local office of the CSCI.
Knowle Hill DS0000002978.V280444.R01.S.doc Version 5.1 Page 17 Timescale for action 01/03/06 2. OP9 13 12/02/06 3. OP11 12 01/03/06 4 OP38 13 12/02/06 All practice drills must be fully recorded. 5. OP38 18 An audit of staff mandatory 01/03/06 training must take place. Where gaps are identified, training must be provided. All identified staff must be provided with food hygiene and moving and handling training. (Previous of 31/12/05 requirement not meet) RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Knowle Hill DS0000002978.V280444.R01.S.doc Version 5.1 Page 18 Commission for Social Care Inspection Sheffield Area Office Ground Floor, Unit 3 Waterside Court Bold Street Sheffield S9 2LR National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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